Treatment in case of incapacity - Mentally challenged people
Treatment in case of incapacity
There are laws and guidelines for how you should deal with people with intellectual disabilities who oppose a (treatment) act.
Laws and guidelines
In principle, you can not treat someone if he does not want to. It does not matter whether the patient is competent or incompetent. This is stated in the Medical Treatment Contracts Act (WGBO). This states that a treatment may only take place with the consent of the patient. And that the patient must be well informed beforehand.
That is not possible with a part of people with intellectual disabilities. They may be incapacitated or not competent in the matter. The latter means that someone is incompetent for a particular situation or decision. For example, someone with an intellectual disability can, for example, be able to decide on his daily routine, meals and clothing, but not on dental treatment.
If incapacity is established, someone else is asked to act as a legal representative. Usually these are the parents, or is that someone who has been appointed by the judge as curator or mentor.
Bopz and bill care and coercion
The Special Admissions Act in psychiatric hospitals regulates the conditions under which incapacitated people can be admitted. This law is not suitable for people with intellectual disabilities and dementia sufferers. That is why there is a new law in the making: the Care and Coercion Act. That law is not yet in force (2016). The new law is not only about admission, but also about involuntary care and small and large (freedom) restrictions.
When someone with an intellectual disability resists a (treatment) act, it is important to look carefully:
- Against which the patient resists;
- Whether the (treatment) action is really necessary;
- Whether coercion (freedom restriction) is necessary and justified.
This applies, for example, to medical or dental treatment, but also to daily care situations that the patient resists, such as eating, moving and performing oral care.
Freedom-limiting measures and resources
There are different degrees of freedom restriction, from stimulation to pressure and coercion. By coercion you can think of: fix the arms and legs, hold the head during a dental treatment, place the patient on a posture-supporting mattress, place a wheelchair sheet, but also administer sedative medication.
According to the Bopz, freedom-restricting measures may only be applied in an emergency situation, if there is a danger to the patient or others and if that danger can not be averted in any other way.
Every freedom-limiting measure must meet the following requirements of the Bopz:
- The application must be in reasonable proportion to the goal: with a 'small', daily goal no heavy measure fits. This is called the proportionality principle.
- The least intrusive measure (the least onerous means) must be applied. This is called the subsidiarity principle.
- The measure must be suitable for achieving the purpose and must not be applied longer than is strictly necessary.
You must state any form of freedom restriction that you apply in the care file.
Examples of freedom limiting agents and measures in oral care are: fixation tapes, holding hands, a mattress that limits the client's ability to move, a mouth spreader and sedation (medication in advance, sedation during treatment or general anesthesia). In the vision document Resistance and freedom restriction in dental treatment of people with an intellectual disability of the Association for the Promotion of Dental Care for Disabled Persons (VBTGG), the following principles apply for the application of freedom restriction:
- Freedom restriction is an extreme means.
- Attendants and supervisors are constantly looking for alternatives.
- The freedom restriction is monitored.
In addition, the vision document advocates preventive policy. The emphasis should be on tailor-made care by competent healthcare providers, based on a vision of autonomy and freedom restriction.